Adam Gordon

Preserving Continence During Robotic Prostatectomy

Preservation of postoperative urinary continence remains the primary concern of all men and their surgeons following robot-assisted radical prostatectomy (RARP). Without doubt, continence is the most important quality of life issue following radical prostatectomy. Identification of difficulties and lessons learned over time has helped focus efforts in order to improve urinary quality of life and continence. This review will examine definitions of continence and urinary quality of life evaluation, technical aspects and the impact of patient-related factors affecting time to and overall continence.

Long-term Outcomes in Severe Lower Urinary Tract Symptoms in Men Undergoing Robotic-assisted Radical Prostatectomy

OBJECTIVE To address a major concern driving treatment intervention, we studied incontinence and urinary quality of life (QOL) before and after robotic-assisted radical prostatectomy (RARP). In men with severe lower urinary tract symptoms (LUTS), this is the first observational study analyzing short- and long-term urinary outcomes of RARP. MATERIALS AND METHODS RARP was performed on 665 patients by 1 surgeon from 2002 to 2007. Men returned preoperative and postoperative self-reported American Urological Association symptom score (AUAss), urinary QOL, and continence (pad usage) questionnaires. Men with preoperative severe LUTS (AUAss ≥ 20; n = 53; 8%) were observed longitudinally for a mean of 4.0 years (range, 1.6-9.4 years) and were compared with men with mild-to-moderate LUTS (AUAss ≤ 19; n = 612; 92%). RESULTS In men with severe LUTS, baseline average AUAss and QOL scores were 24.8 and 4.0, respectively. Long-term AUAss improved by 70% (17 points; P < .001); specifically 59% of patients had AUAss drop to <8, 35% of patients to 8-19, and 6% of patients remained at ≥ 20. The mean QOL scores declined from 4.0 to 2.0 (P < .05). Preoperatively, 38 of 52 patients (73%) had a poor QOL score of 4-6 compared with only 18% (P < .001) at long-term follow-up after RARP. Overall pad-free status was 71% vs 89%. CONCLUSION In men with severe LUTS, RARP significantly improved urinary symptoms and QOL scores with an overall pad-free status of 71%. Specifically, these men should be counseled that RARP confers a significant short- and long-term benefit with regard to relief of their obstructive and irritative symptoms.

Analysis of Improved Urinary Peak Flow Rates After Robot-Assisted Radical Prostatectomy

PURPOSE Longitudinal assessment of prostatic obstruction has historically been assessed with urinary peak flow rates (PFR). In this observational study, we assess the impact of prostate removal on preoperative and postoperative PFRs after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS A single surgeon (TA) performed RARPs between 2002 and 2007. Men underwent routine preoperative uroflowmetric testing: 550 qualified for analysis with a sufficient voided volume (VV) of 150 mL preoperatively and at least once postoperatively. Continence and self-assessed American Urological Association (AUA) symptom and urinary quality of life (QoL) questionnaires were queried. Uroflows were analyzed preoperatively, short-term (3-15 mos), long-term (>2 y), and by age decades, lower urinary tract symptoms (LUTS) groups, and pathologic weight cohorts. RESULTS AUA and QoL scores improved from 8.1 and 1.6 at baseline to 4.4 and 1.0 at intermediate-term follow-up, P<0.01. Mean PFRs improved from a baseline 18.0 mL/s to 28.3, 30.8, and 36.5 at 3 months, 9 months, and >5 years follow- up (all P<0.001). Postvoid residual (PVR) volumes declined from 99 mL preoperatively to 24 mL at >5 years (P<0.01). Likewise, all age, LUTS, and prostate weight cohorts had significant improvements in PFR and PVR and stable voided volumes throughout the study. CONCLUSION The natural history of prostatic obstruction for men 40 to 80 years typically reveals reduction of mean PFRs. We observed that removal of the prostate resulted on average with a near doubling of PFRs and decreased PVRs (>50%) by 3 months. After RARP, the average PFR was reset to 25-30 mL/s, and these results were seen across all age, LUTS, and prostate weight groups; the gains remained stable 2 to 4 years after operation.

Urinary nerve growth factor as an oncologic biomarker for prostate cancer aggressiveness

OBJECTIVES We investigated urinary nerve growth factor (NGF) as a novel urinary biomarker for high-grade prostate cancer (PCa). METHODS AND MATERIALS After institutional review board approval for a prospective pilot study, we enrolled men at the preoperative visit before robotic-assisted radical prostatectomy. Demographics, urinary flow parameters, and urine samples were collected. Urinary NGF and urinary creatinine were obtained in the translational science laboratory. Pathologic and postoperative demographics were collected after surgery. NGF is the primary outcome variable (dependent variable). The pathologic Gleason score (ordinal variable ≤6, 7, and ≤8) served as an independent grouping variable. Multivariate analysis using a general linear model was conducted to investigate associations between independent variables and NGF (dependent variable) after adjusting for urinary concentration and volume. RESULTS We enrolled and analyzed urine samples and pathologic data from 115 subjects. Patient pathology included 24% (n = 28) Gleason score 6 or less, 68% (n = 78) Gleason score 7, and 8% (n = 9) Gleason score 8 or greater. Perineural invasion was more prevalent in higher-grade disease (P<0.001). The median NGF level was 24.1 pg/ml (range: 0.16-270.5 pg/ml) and was transformed to the log base 10 scale. Total bladder volume, urinary creatinine level, prostate-specific antigen level, and diabetes were correlated with the Log NGF. In a general linear model, adjusting for bladder volume and urinary creatinine, increasing Log10 NGF was associated with higher Gleason score (Gleason category ≤6, 7, and ≥8; P = 0.003). CONCLUSIONS Urinary NGF may be a biomarker for higher-grade PCa. Our pilot study suggests further investigation is warranted to determine whether urinary NGF could provide unique additional information in patients with PCa.

Continence Postcards versus Urinary Pad logs: Simple Methods to Measure Early Pad Free Urinary Continence after Radical Prostatectomy

Introduction: We evaluated whether a simple postcard reporting the date of becoming pad‐free is accurate compared to a daily log of pad use to determine time to pad‐free status after robot‐assisted radical prostatectomy. Methods: Prospectively at the time of discharge home we gave 439 men treated with robot‐assisted radical prostatectomy between April 2010 and September 2014 a self‐addressed stamped postcard to mark the date they attained pad‐free urinary continence. In addition, we concurrently asked the men to fill out a daily urinary log of pad use to be faxed or emailed. Results: Of the 439 men 193 (44%) reported their pad‐free status via postcard and pad use log. The correlation of time to pad‐free status via postcard compared to daily log was R2 = 0.98 (p <0.0001). Overall of the 439 men 292 (66%) returned a postcard and 309 men (70.4%) returned a urinary log. However, only 239 (54.4%) of the logs contained the date of pad‐free status and, thus, the continence cards were more likely to report pad status correctly (p <0.001). In addition to the 66.5% continence card rate 7.7% of the logs provided additional pad‐free dates, resulting in a combined pad‐free return rate of 74.3%. Conclusions: Patient reported continence postcards or pad use logs are a simple, inexpensive and reliable way to determine pad‐free continence after radical prostatectomy. Either method offers surgeons a low cost, dependable and easy way to track pad‐free continence outcomes and their combined use resulted in a nearly 75% response rate.

Quantification of Long-term Stability and Specific Relief of Lower Urinary Tract Symptoms (LUTS) After Robot-assisted Radical Prostatectomy

OBJECTIVE To assist in preoperative counseling by assessing long-term changes in American Urological Association symptom scores (AUAss) and lower urinary tract symptom (LUTS)-related quality of life (QOL) in patients undergoing robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS RARP was performed on 666 men by one surgeon from 2002 to 2007 at a single institution. AUAss and QOL were queried preoperatively and at 3, 9, 15, 24-48, 60-84, and 96+ months postoperatively. LUTS subgroups were compared pre-/postsurgery using univariate and multivariate statistics. RESULTS The mean and median follow-up for all responders was 3.0 and 2.4 years. Pad-free continence at 12 months was 89%. A subset of 174 men reported preoperative and long-term responses; average follow-up was 5.8 years (range 4.0-10.3 years). AUAss for all men declined from baseline to 5 years by 3.7 (8.6 to 4.8) whereas QOL/Bother scores decreased by 0.5 (1.7 to 1.2) (all P < .05). Men with baseline mild LUTS remained clinically unchanged with long-term AUAss. Individuals with moderate and severe preoperative LUTS had marked improvements in AUA and QOL scores (all P ≤ .05). CONCLUSION Men with mild LUTS have short-term increases in AUAss but most return to baseline and are stable at 5 years. Benefits were found for men with preoperative moderate and severe LUTS in that 63% had significant QOL improvements and 68% reduced their AUAss to mild LUTS, persisting years after RARP. This study suggests that certain patients with preoperative urinary symptoms and bother may experience improvements in LUTS and associated QOL after RARP.

Diminished long-term recovery of peak flow rate (PFR) after robotic prostatectomy in men with baseline PFR <10 mL/s and incidental association with high-risk prostate cancer

The aim of this study was to evaluate the effects of robot‐assisted radical prostatectomy (RARP) on uroflowmetry (UF) parameters among men with baseline peak flow rates (PFR) <10 mL/s.

Monocyte Chemotactic Protein-1 (MCP-1) as a Predictor of Prolonged Urinary Incontinence After Radical Prostatectomy

Author(s): Liss, MA; Ahlering, TE; Morales, B; Gordon, A; Osann, K; Skarecky, D; Lusch, A; Zaldivar, F; Ghoniem, GM | Abstract: